Example: biology

PLEASE PRINT THE FOLLOWING INFORMATION

Authorization to Release Information I herby authorize Lone Star College System to conduct a background review of my personal history, including but not limited to, my education, previous employment, driving record, any public records,

Tags:

  Information, Please, Print, Please print

Information

Domain:

Source:

Link to this page:

Please notify us if you found a problem with this document:

Other abuse

Text of PLEASE PRINT THE FOLLOWING INFORMATION

Authorization to Release Information I herby authorize Lone Star College System to conduct a background review of my personal history, including but not limited to, my education, previous employment, driving record, any public records, social security number and previous and current addresses. I understand that this background review may require fingerprinting by a licensed peace officer of the State of Texas and will include a review of any criminal history information maintained by federal, state, county or local criminal justice agencies, courthouses, or criminal record repositories. I herby authorize any entity, agency or other company to release such information to Lone Star College System upon receipt of this request letter. I understand that the information released is for official use by Lone Star College System. I further understand the information released shall be privileged and confidential, and shall not be released or otherwise disclosed to any other person or agency except under court order. I hereby release, discharge and hold harmless, Lone Star College System, its Board, officers, employees and agents from any and all liability for any or all claims that arise or may arise as a result of the inspection, investigation, use or preparation of any reports documents or data regarding the review or investigation of my background. ________________________________________ __ ______________________ Applicant/Volunteer Date ________________________________________ __ _______________________ Witness Date PLEASE PRINT THE FOLLOWING INFORMATION: Full Name: __________________________ ______________________ ______________ Last First Middle Social Security Number: _______ -_____-_______ Date of Birth: ______/_____/______ MM DD YYYY Driver s License No: _______________________ State of Issuance _____________________ Have you ever been convicted of, or received deferred adjudication for any violation of criminal law? ____ yes _______ no If yes please describe circumstances___________________________ _______________________ ________________________________________ _______________________________________ * Ethnicity: ________________________________________ ____________ (White, African-American (Black), Asian/Pacific Islander, Hispanic, etc.) *This information is totally voluntary and will be used only for reporting requirements. SECTION 1: TO BE COMPLETED BY THE HIRING DEPARTMENT: To the Human Resources Department/Human Resources Manager: ____________________________ is a: _____________________________(job title) (check one) Candidate with conditional job offer __________ ___________________(reference # if posted) Student worker _________ Volunteer__________ Please forward to the LSCS Police Department to initiate a background check. ________________________________________ _________ Hiring Authority Name (Please print) Signature: ____________________________ Title:________________________ Date: __________ SECTION 2: TO BE COMPLETED BY THE HUMAN RESOURCES OFFICE/HUMAN RESOURCES MANAGER UPON NOTIFICATION THAT THE SELECTED CANDIDATE HAS ACCEPTED THIS POSITION To the LSCS Police Department: Be advised that____________________________ has accepted a conditional offer of employment/volunteer assignment at ________________College/LSCS. Attached please find the Authorization to Release Information. Please conduct a criminal background check so that the department s conditional offer may be finalized. Signature:______________________________ __________________ Date: ___________________ HR Department/HR Manager (Send to AVC/HR for approval. AVC/HR will forward to Police Department) Signature:______________________________ __________________ Date: ___________________ Associate Vice Chancellor for Human Resources/Designee SECTION 3: TO COMPLETED BY THE LSCS POLICE DEPARTMENT UPON COMPLETION OF THE CANDIDATE S BACKGROUND CHECK To Associate Vice Chancellor for Human Resources: Be advised that the criminal background check on _____________________________ is complete, and the results are: _______ Satisfactory _______ Unsatisfactory Signature: ___________________________________ Date: ___________________ Police Officer

Related search queries